Sunday, 21 October 2007

Classificatory Systems

Classificatory Systems

For various organic and psychological reasons some people will behave markedly differently from the majority of others.

It wasn’t until the mid nineteenth century that scientists, notably Jean Martin Charcot in Paris and Sigmund Freud in Vienna began to note how some symptoms in patients with abnormal behaviour frequently occurred together.

Freud’s earliest classification system distinguished between three groups of disorders. They were:
· Neuroses – Phobias which were mild and didn’t require medical attention;
· Psychoses, e.g. Dementia Praecox (Schizophrenia) which were severe and could be life threatening;
· Personality Disorders e.g. excessive timidity, excessive aggressiveness etc which were permanent.

“Signs” are the manifestations of a condition that can be observed and measured.
Changes in your temperature, blood pressure, cholesterol level, weight and how frequently you use the toilet etc.
A cluster of signs and symptoms that generally occur together is called a “syndrome” which indicates the existence of a particular disorder.

The American Psychiatric Association (APA) has published four editions of its Diagnostic and Statistical Manual (DSM-IV) which lists the syndromes of disorders. This is used by American psychiatrists and psychologists for basis of diagnosis.
The WHO (World Health Organisation) has developed another classification of disorders called the International Classification of Diseases (ICD) now in its tenth edition (ICD-10). However, this is not used specifically for diagnosis.

Describing Mental Disorders:
DSM-IV defines a mental disorder as a syndrome that is associated with the individuals condition at the present time or with the increasing likelihood that they might suffer from it in the near future. It leads to them behaving dysfunctionally. We need to distinguish between classification and diagnosis.

This is deciding what something is e.g. schizophrenia as opposed to depression and what the characteristics of the different types are.
What happens when we look at one particular example. In mental health diagnosis is the clinical judgement that a particular person is suffering e.g. schizophrenia.

The classification of mental disorders:
Main purpose of classification systems is being able to generate agreement between psychiatrists and mental health care professionals as to:
The recognition of symptoms (Subjective experience of the patient or client);
Signs (Objective or measurable, such as high temperatures);
and Syndromes (Clusters or signs and symptoms that occur together.)
Some psychologists are sceptical about the categorisation of clusters of signs and symptoms into syndromes and the classification of syndromes as the bases for diagnosis.

Since every individual is a unique fusion of all their biological and social experiences, classifying behaviours into syndromes is unhelpful to understanding their unique perceptions, and misleading if used to imply a course of ‘treatment.’
· The ICD classification system dates back to 1893,
· ICD-10, published in 1992 by the World Health Organization (WHO), is a large work consisting of three volumes and over 2,000 pages.
· The primary function of the ICD is to make it easier to collect and report general health statistics.
o Mental disorders were not included until the sixth revision in 1952 (ICD-6).
Main purpose = to gain agreement on a universal definition for specific disorders or syndromes. This helps to ensure that whenever research is carried out on a disorder with a particular set of symptoms, the disorder can be universally recognized. Without agreed definitions and labels, it would be difficult for researchers and clinicians to communicate effectively. ICD-10 identifies 11 general categories of mental disorders, listed below:

· While the primary purpose of ICD is the classification of disorders, the DSM classification system has an additional purpose of assisting clinicians to diagnose a person’s problem as a particular disorder. Clinicians can also use the available information on a given disorder to decide on the most appropriate course of treatment. The American Psychiatric Association first published the Diagnostic and Statistical Manual of Mental, Disorders (DSM-I,)
· DSM-l and DSM-II (published in 1968)
· DSM-III (published in 1980) included many more disorders than its predecessors.
· DSM-IV, (Current version) was developed in 1994 and a text revision’ — DSM-IV-TR — was published in June 2000.
· DSM-IV-TR lists around 400 disorders covering clinical disorders , personality disorders and mental retardation.
· DSM-III saw the first use of multi-axial classification, which is used to rate an individual on five separate dimensions (Or axes) that may affect functioning.

A mental disorder may be defined as “…a clinically significant behavioural or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (E.g. a one or more important arreas of functioning) or with a significant increased risk of suffering death, pain, disability or an important loss of freedom.” (DSM-IV)

State University of New York at Buffalo, Lecture 2 (1999) criteria for a useful classification system:
· Provide an Exhaustive system that includes all types of abnormal behaviour;
· Classificatory categories should be mutually exclusive;
· Must be valid;
o Content validity;
o Criterion validity;
o Construct validity;
· Must be reliable.

Critical Issues in classification:

Are the categories of mental illness real and meaningful?
Each disorder is a distinct entity
Must not consider them merely to be ‘figments of scientists’ imaginations’ (SUNYB2 1999)
When description becomes diagnosis:
It is important to appreciate that terms used in psychology, including those used in clinical psychology have a variety of meanings and can refer to different things.
The description becomes the explanation – a circular and thus meaningless explanation is set up. The description is used to explain itself! (SUNYB2 1999, pp. 7-8)
Over inclusion and ‘pathologizing’ problems:
Comer (2004) suggests that as high as 48% of the adult population of the USA might qualify for a diagnosis on the DSM.
Improved specificity:
When using DSM-IV-TR and ICD-10 clinicians have found that previous editions did not spell out the criterion for inclusion clearly enough, leading to misdiagnosis (Oltmanns & Emery, 2004)
DSM-IV-TR contains exclusion criteria, which means that some specific diagnosis may be ruled out under certain conditions.

Some things in the world are real and you can touch them.
Is a condition however real or a socially created concept must be asked at frequent occasions.
If you believe that schizophrenia is an organic disorder, with certain parts or functions of the sufferers brain not working properly, and that drugs or surgery or other physical treatment will be able to fix that you may say that schizophrenia is ‘real’.

If you believe that humans are capable of a vast range of alternative cognitions and behaviours it is only because society has evolved to accept that some are right and acceptable because they conform to socially generated norms while those that do not are considered deviant and disordered then you may think that schizophrenia is a socially created concept.

Labelling is a process by which people are defined in a way that makes others treat them according to their label

Professional bodies such as APA and BPS insist that present classification systems should be used to enable diagnoses to be made, not to attach labels.
Even terms used in clinical psychology can refer to different things and that those terms can be quite closely related to others.

Sometimes in clinical psychology peoples behaviour is attributed to their condition.

Research into the reliability and validity of classification and diagnosis:

Reliability simply means consistency. It is reliable if we lead to the same diagnosis when given the same signs and symptoms in the future.

Validity refers to accuracy of description. It concerns the concepts used describing the same set of signs and symptoms in different people. It is the accuracy of describing real signs and symptoms that enable real syndromes to be accurately labelled.

Sadly the record for accuracy and agreement amongst psychiatrists on these matters has been very poor indeed. Several studies have found disturbing errors and inconsistencies.
Studies have shown that even very inexperienced psychiatrists may only agree about 50 per cent of the time (Spitzer and Williams 1985)

Aaron Beck (1976) had 153 patients diagnosed separately by two experienced psychiatrists on admission to hospital. For only 83 patients (54%) did they make the same diagnosis.

Key research: Classification and diagnosis – on being sane in insane places. (Rosenhan 1973)

· Nine healthy people presented themselves at different psychiatric hospitals and said they were hearing voices saying things like ‘empty’ and ‘thud’;
· All were admitted, and all except one, diagnosed with schizophrenia;
· Changed names and jobs, but all other info given to hospital was true;
· On admission all eight stopped simulating symptoms of abnormality;
· Never detected
· Eventually discharged with a diagnosis of schizophrenia in remission.
· Hospitalization was from 7 to 52 days – averaged 19.
· Other patients detected their sanity
· Rosenhan suggested that psychiatrists are unable to determine who is sane and who is insane.
· Is it fair to accuse psychiatrists of t6his on basis of this study?
o Hearing voices is the most common diagnosis of schizophrenia
(Davidson et al. 2004)

Rosenhans (1973) study raises questions about validity of the DSM, i.e. how well a measuring instrument really measures what it is designed to measure.

Validity for mental illness is less than physical illness;
Construct validity is determined for schizophrenia by observing the extent to which a person when given this diagnosis then behaves in a way that can be predicted;
Criterion validity may be verified if a sufferer has similar associated problems to others with the same diagnosis and as generally the case they may have difficulty forming relationships.

With each new edition of the DSM, attempts are made to improve both the reliability and validity of the diagnostic criteria. The current version is considered to have reliability and validity for most of its anxiety disorder and mood categories (Brown et al. 2001).
In contrast, its validity for some of the other classes such as personality disorders has been questioned, as has the validity of axis 5 (GAF scale) (Moos et al. 2000).

Use of a computer programme, the Composite International Diagnostic Interview (CIDI) developed by Andrews and Peters (1997) in Australia, claimed to improve reliability and validity, although it wont be apt. for those suffering the more intense consequences of schizophrenia or depression, who may be unable or unwilling to use the machine.
If certain symptoms are endorsed and they occur in certain patterns or clusters, a clinical diagnosis is made. All of this is carried out automatically by the computer programme.

Bias in the diagnosis of mental disorders:
Social class:
Diagnoses were more likely to be as the more serious conditions and;
Treatments more likely to be harsher, inc. drugs and ECT
And were more likely to take longer and be disabling rather than empowering.

People from poorer backgrounds may have a poorer educational experience and be less able to express themselves clearly when describing their symptoms.

Umbenhauer & DeWite (1978) found that upper class people were treated more favourably and were more likely to experience psychotherapy than working class.

Pilgrim & Rogers (1993) suggest that a lack of self esteem results from vulnerability related to employment and is an important predictive factor in the development of mental illness.

Self knowledge of ones position in society and the possible consequences of this may make real mental illness more likely.

Sociogenic theory suggest that poorer people in society are placed under the greatest stress and that this, in turn, makes mental illness more likely (Susser et al. 1996)

Social selection theory proposes that people who suffer from schizophrenia become or remain poor because they are unable to function correctly / effectively (Munk & Mortensen 1992) i.e. they exhibit a drift downwards in society (Davison et al. 2004)


Institutional racism is used to convey the idea that an entire organisation has some principles and practices built into its structure and functions.

Three possible explanations exist for differential rates of diagnosis based on race:

· Western bias on diagnosis of non western people;
· Genetic predisposition of disorders by people from non western and western backgrounds;
· Differences between people from different backgrounds.

People from different backgrounds may simply be more prone to some disorders than others.

Cochrane and Sashidharan (1995) point out that there is a common assumption that the behaviours of the White population are normative and any deviation from this by another ethnic group reveals some racial or cultural pathology.

Sue & Sue (1999) states that African Americans may be suspicious of white clinicians based on previous prejudices experienced. This may be mislabelled paranoia.


There are genetic differences between the sexes that pre-dispose each to suffer from some disorders more than others. Another reason being that socially prescribed gender roles over the last few centuries have led each sex to have different expectations about their roles, and when these expectations are not met, behaviour and cognitions may become distorted in different roles.

Broverman et al. (1981):
· Found that clinicians have different concepts of health for men and women and that these differences do tend to be parallel the common gender role stereotypes in our society.
· Asked 46 and 33 female mental health professionals to rate the characteristics of the healthy man, woman, and adult.
· The healthy woman was regarded as more submissive dependant and emotional than the healthy man.

· Certain behavioural characteristics thought to be pathological in members of one gender, but not in the other gender.

Worell & Remer (1992) claim that sexism can occur in assessment and diagnosis of patients in four ways:

Disregarding the environmental context
· Such as poverty patriarchy and powerlessness.
Differential diagnosis based on gender
Therapist misjudgements
Theoretical orientation gender bias.

· One of the dangers of mental health professionals adopting the adjustment view of health is that they then actively reinforce and perpetuate gender role stereotypes (Nolen-Hoeksema 2002)

Diagnosing the person or the situation:
· Western culture predisposes women to depression. Cochrane (1995) links this to long term child abuse which links to increased female vulnerability.
· Also she believes that unemployed men have a higher rate of breakdown and by labelling the problem as a disorder stigma is attached.

Concepts to note:
Define these terms:
· The American Psychiatric Association;
· (CIDI) (Composite International Diagnostic Interview);
· Diagnosis;
· Dissociative disorders;
· (DSM) (Diagnostic and Statistical Manual);
· (lCD) (International Classification of Diseases);
· Labelling;
· Organic Disorder;
· Reliability;
· Sign;
· Socially Created Concept;
· Somatoform disorders;
· Symptoms;
· Syndrome;
· Validity;
· WHO (World Health Organisation)

What did they do or say?
· Beck
· Broverman
· Cochrane and Sashidharan
· Hamilton
· Howell
· Johnstone
· Rack

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